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TOWN OF YARMOUTH HEALTH DEPARTMENT
FOOD ESTABLISHMENT
ANNUAL LICENSE APPLICATION
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uAtrlNc ADDRESS (if differ{nrr?C Box .?? f -{."y' l,7).rn. </t/* ,) /4a
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MANAGER'CONTACT PERSON PHO\E +
NAM, (IF APPLICABLE)
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CORPORATION
FOOD PROTECTTON MANAGER(S)
All food service cstablishments are required to have at least one ( l) full-rime 4ified FOOD PROTECTION MANAGER on staff.
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PERSON IN CHARGE
All food service establishments must have at least one (l) PERSON tN CHARGE on site during hours ofoperation
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ALLERGEN CERTIFICATIONS
All food service establishments are required to have at least one (l ) illl-time ALLERGEN CERTIFIED staff member
HEIMLICH CERTIFICATIONS
All food service establishments with twenty-five (25) seats or more are required to havc at least one ( I ) employee ffained in thc
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l.lElMl-lCH MANEt]VER on site d hours of tlon
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PLEASE LIST STAFF ]IIEN{BERS WHO HOLD THE FOLLOWING CERTIFICATIONS AND ATTACH
COPIES OF CERTIFICATIONS TO THIS APPLICATION.
RISTAURANT SEAI'ING 'IOTAL NO. :
TOTAL SQ. FOOTAGE:
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A WORKf,R'S COMPENSA'I'ION AF!'ID IT MI]ST BI,] A'I"I'ACHED \\'ITH THIS APPLICA'IION
The Town of Yarmouth taxes and liens must bc paid prior to renewal or the issuance ofyour licenses
Please check if appropriately paid:
YExNotr
NOTICE:
LICENSES RUN ANNUALLY FROM JANUARY I TO DECEMBER 3I, IT IS YOUR RESPONSIBILITY TO RETUR\ THtr
CONIPLETED RENE\IAL APPLICAl'IO\(S) AND R EQUrrar,D [-EU(S) Ar_L RENOVATIONS TO ANy FOOD
ESTABLISHMENT (PAINTING, NEW EQUIPMENT, E ) MUST BE REPORTED TO AND APPROVED BY TI]E BOARD OF
HEALTH PRIOR COMMENCEMENT NOVATIONS MAY I{EQUIRE MA ENCINEER SIl'E PLAN
SIGNATURE
PRNT NAME & TITLE lai /t,o -, 6 h,o 0 ,o"t<-z
l.'ooD sERVlctl
SEASONAL FOOD SERVICE OPENING:All food service establishments n:ust be inspected by the Health Depanment
prior to opening. Please contact the Health Dcpanment to schedulc the inspection three (3) days prior to openrng.
CATERING POLICY .Anyone who catcrs within the Town of Yarmouth must noti! the Yarmouth Health Department by
filing the required Temporary Food Service Application form seventy-two (72) hours prior to the catered event. These
forms can be obtained at the Health Department, or from the Town's website at www.yarmouth.ma.us under Health
Department. Downloadable Forms.
FROZEN DESSERTS: Frozen desserts nust be tested by a State certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of
your Frozen Dessert License until the above terms have been mct.
OUTSIDE CAFES: Outside cafes (i.e., outdoor seating with server service), must have prior approval from the Board of
Health.
OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service
establishment is prohibited.
fe.qllsris.e:
0-100 sEATs - $125.00
>100 SEATS - $200.00
Contin€ntal - $35.00
Common Vic - $60.00
Non-Profit - $:10.00
Wholesale - $80.00
Residential Kitchen - $80.00
ItrtxilScrvicc:
<50 sF - $50.00
<25.{}0{} Sl. - :1150.00
>25.000 sF - $285.{}0
F-rozrn l)csscr( - :110.{x)
Vending lirod - $25.00
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I-ICENSE FEES:
Certificote of Achievement
This cerlificote is oworded to
WILLIAM DONAHUE
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ASIM t2659
Congrotulotions! You hove completed
ServSofe'Food Hondler
cerrificore Number 6629493 D"t" 101212023
Notionol Restouront Associolion
233 S. Wocker Drive, Suile 3600
Chicogo, lL 606066383
80O.765 2122 in Chicogo oreo 31 2.2l5 1010
Reslouronl.org I ServSofe.com
ICCRED]IED
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Expiroiion Dore 101212026
CERTIFICATE
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William Donahue
has successfully completed the required Allergen Awareness program for
Al lergen Awa reness Certifi cati on
Valid through:
Course Reference:
#1203
? /21/2026
Nick Eastwood
President
The Always Food Safe Company
the
Date Completed:
Certificate #:
2/21 /2023
2113295Alwoys
Sofe'compony
The Always Food Safe Company
899 Montreal Circle, St. Paul, 55102
www.alwaysfoodsafe.com | 844.312.201 1
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ACCFEDIIEO